British Joumlof Urology (1992),70,60&602 01992 British Journal of Urology
Extracorporeal Lithotripsy of Ureteric Calculi Using the Dornier H M-3 Lithotriptor E. BENIZRI, M. AUGUSTI, G. AZOULAI, L. CHARBIT and J. CUKIER Department of Urology, HSpital Necker, Paris, France
Summary-Over a 5-year period (November 1984-November 1989), we treated 356 patients with ureteric calculi; 170 were treated by extracorporealshock wave lithotripsy (ESWL) on a Dornier HM-3 lithotriptor. The calculi (n= 176) were uniformly distributed along the length of the ureter: 44 were just below the pelviureteric junction, 59 were lumbo-iliac, 42 were in the upper bony pelvis and 32 in the lower bony pelvis. The mean diameter of the upper ureteric calculi was 10 mm and for the others it was 8 mm. Thirty-four patients with acute obstructive pyelonephritis required preESWL drainage of the urine. X-ray localisation required intraveneous urography during lithotripsy in 52 cases (30%).On plain X-ray the following day 170 stones (96%) were judged to have disintegrated. The 6 patients whose stones were not fragmented received further treatment (ureterotomy (4) and ureteroscopy (2)). Five patients required additional treatment because of pain or fever (catheterisation (3) and ureterotomy (2)) and 2 patients had a second lithotripsy owing to insufficient fragmentation. Four patients were lost to follow-up. In 153 patients (90%) the fragments were eliminated completely, 146 in the first month and the remainder before the sixth month. No serious sequelae were observed. In addition to the 5 patients who required supplementary treatment. 11 patients with pain or fever needed medical treatment. We recommend first intention in situ ESWL for all ureteric calculi.
The aim of this study was to demonstrate the possibility of treating virtually all ureteric calculi by ESWL. Such calculi were initially excluded from ESWL by Chaussy et al. (1980, 1982). Miller et al. (1985) published the first report of success with upper ureteric calculi.
Patients and Methods In France, the first ureteric calculi were treated at the Centre Inter Etablissements de Lithotriptie of the Assistance Publique de Paris in 1984. From November 1984 to November 1989, using the Dornier HM-3 lithotriptor with X-ray localisation, 176 ureteric calculi were treated by ESWL. The study group included 170 patients (134 men and 36 women) whose mean age was 40 years (range 784). Two patients underwent 2 consecutive ESWL sessions, so that the total number of treatments was Accepted for publication 12 July 1991
172 for 170 patients. Six patients had 2 ureteric calculi, making a total of 176 calculi in 170 patients. The distribution of the stones according to size and location is shown in the Table. Before treatment all patients underwent intravenous urography (IVU), urine analysis, blood count and coagulation tests. Plain X-rays of the abdomen, AP and lateral, were done immediately before lithotripsy. In 34 patients, acute obstructive pyelonephritis required prior drainage of the urine Table Distribution of Calculi According to Position Size (mm)
Upper ureter
Lumboiliac
15 Distribution
0 33 6 5 44 (25%)
9 9 44 21 5 4 1 2 59 (33%) 42 (24%)
600
Upper pelvic
Lower pelvic 8 11
5 1 31 (18%)
ESWL USING THE DORNIER
60 1
HM-3 LITHOTRIPTOR
(32 times by a ureteric catheter alongside the (2) for inadequate fragmentation. Four patients could no longer be contacted. calculus and twice by percutaneous nephrostomy). Thus 166 patients with 172 ureteric calculi were Regardless of the position of the calculus, its initial localisation was attempted in the conven- assessed. A total of 153 patients (92%) eliminated their tional half-sitting position. If the localisation time approached 605 without having found the stone, fragments completely (146 (88%) in the first month the patient's position was changed and an IVU was and 7 (4%) before the sixth month). The 6 immediate failures have been discussed. obtained. Some iliac calculi were localised in the prone position and pelvic calculi that were uniden- Of the remaining 166 calculi, 159 were eliminated tifiable in the outstretched position were localised without supplementary treatment (92.5%). Seven in the seated position. The lack of visibility of the required supplementary treatment. In all, 164/172 calculus was sometimes overcome by performing calculi were eliminated without surgery or ureteran IVU during localisation (52 times; 30% of the oscopy (95.3%). cases). Before 1989 it was necessary to use general Discussion anaesthesia 43 times, epidural anaesthesia 78 times and sedation 17 times to supplement premedication. Of 356 ureteric calculi treated between 1984 and Of 74 treatments carried out since 1989, no general 1989, 176 were treated by ESWL, 149 by open anaesthesia was required, but 16 patients had ureterotomy and 31 by ureteroscopic extraction. epidural anaesthesia, 26 sedation as well as preme- The percentage treated by ESWL rose steadily dication, and 32 had premedication alone. The (Fig.). Thus in 1989, 70/74 ureteric calculi (94.5%) number of shock waves per calculus ranged from were destroyed by ESWL and the remaining 4 removed by ureterotomy. 2000 to 4000. For sub-pelvic, upper lumbar and lower pelvic Lithotripsy was terminated on the basis of an impression of a change in the contour of the texture calculi, regardless of the method of localisation, of the X-ray image of the calculus rather than the success rates of over 85% have been reported. When certainty of disintegration proved by the dispersion lithotriptors with ultrasound localisation were used, success rates ranged from 79 to 86.5% (unpublished of sand. The urine was usually haematuric after litho- material). For lithotriptors with X-ray localisation tripsy: in addition, 11 patients complained of the success rate was 90% (Coptcoat et al., 1987; lumbar pain and 5 had a fever ( < 38.5"C). Anti- Lingeman et al., 1987; Fetner et al., 1988; Graff et spasmodic and anti-inflammatory treatment was al., 1988; Ikemoto et al., 1988; Lupu er al., 1988; prescribed 11 times. Antibiotics were given only to Chatelain et al., 1990). Calculi in these sites are pyuric and bacteriuric patients. A plain X-ray of extremely amenable to lithotripsy, especially if the abdomen was taken on the following day to localised by X-ray. assess fragmentation. If fragmentation appeared For lumbo-iliac and upper pelvic calculi, ultrasatisfactory, follow-up was confined to plain X-ray, sound localisation produced poor results ( < 50% cytobacteriological urine analysis and renal echography 8 and 45 days later. No.
Results Patients who eliminated their stones completely were considered cured. The absence of fragmentation indicated failure and fragmentation with incomplete elimination indicated residual calculi. On the plain X-ray taken 24 h after treatment, 170/ 176 calculi were fragmented (96%). Of the 6 patients (3.5%) whose stones were not fragmented, 4 were treated by ureterotomy and 2 by ureteroscopy. Seven patients (4%) received supplementary treatment because of pain or fever, although the calculus was fragmented : ureterotomy (2 patients), catheterisation (3) and repeat ESWL
70
/
\
1/ 1 ESWL 2 Ureterotomy 3 Ureteroscopy
40
30
1985186
1986187
1987188
1988189
Fig. Treatment of ureteric calculi at HBpital Necker.
602 success rate for the former and 65% for the latter) (unpublished material). Our localisation problems were overcome by intravenous urography (52 times) during lithotripsy, combined if necessary with a change in the patient’s position. For lumbar calculi, Fetner et al. (1988) reported 138 patients (83%) cured 6 weeks after in situ ESWL without catheterisation. Our results are similar, with an 85% success rate in 1 month. For iliac calculi, 2 problems had to be overcome : interruption of the shock wave by the iliac bones and the sacrum when the waves penetrate from behind, and the ability to localise a stone positioned far in front of the focus F2 of the ellipsoid of revolution. Jenkins and Gillenwater (1988) and Tiselius et al. (1988) were the first to suggest lithotripsy in the prone position, except for sexually active women because of the risk of irradiating the ovary. Iliac localisationled to a success rate of 90% at 6 months. Jenkins and Gillenwater (1988) and Tiselius et al. (1988) reported success rates of 93 and 87.5% respectively. These good results can be ascribed to X-ray localisation. This zone is invisible to those using ultrasound localisation. For upper pelvic calculi, opinions vary. Some authors feel that pelvic stones are amenable to ureteroscopic extraction (Coptcoat et al., 1987; Ikemoto et al., 1988; Zerbib et al., 1990), but we believe it is simpler to use ESWL first. In the present series, 42 upper pelvic calculi were treated in situ without endoscopic manipulation, with a 93% success rate after 1 month. Chatelain et al. (1990) reported a success rate of 98%. Two calculi that were superimposed on the transverse process of L5 could not be localised despite using all of the methods described above and they were treated by ureterotomy. Four calculi (2 pelvic, 1 lumbar and 1 sub-pelvic) underwent ESWL without fragmentation. The absence of postESWL haematuria in these patients leads us to believe that the shock waves were not focused on the urinary tract. Two patients underwent ureterotomy and 2 ureteroscopy. A success rate of 96.5% at 6 months justifies our claim that in situ ESWL with an X-ray localisation lithotriptor is an excellent method for treating
BRITISH JOURNAL OF UROLOGY
radio-opaque ureteric calculi, irrespective of their position.
References Chatelain, C., Connort, P., Ledenko, N. et d (1990). Lithotriptie extra-corporelle par ondes de choc klectromagnktiques. Premiers rksultats dans le traitement de la lithiase urtrtkrale in situ. SCrie de 50 cas conskcutifs. Ann. Urol. (Paris), 3, 232235. Chaussy, C., Breudel, W. and Schmidt, E. (1980). Extracorporeally induced destruction of kidney stones by shock waves. Lancet, 2, 1265. Chaussy, C., Schmidt, E., Jocham, D. et al. (1982). First clinical experience with extracorporeally induced destruction of kidney stones by shock waves. J. Urol., 127,417420. Coptcoat, M. J., Webb, D. R., Kellett, M. J. et d (1987). The treatment of 100 consecutive patients with ureteral calculi in a British Stone Centre. J. Urol., 137, 1122-1 123. Fetner, C. D., Preminge, G. M., Seger, J. e t d (1988). Treatment of ureteral calculi by extracorporeal shock wave lithotripsy at a multi-use centre. J. Urol., 139,1192-1 194. Graff, J., Pastor, J., Funke, P. J. et d (1988). Extracorporeal shock wave lithotripsy for ureteral stones: a retrospective analysis of 417 cases. J. Urol., 139, 513-516. Ikemoto, S., Sugimoto, T., Yamamoto, K. et d (1988). Comparison of transurethral ureteroscopy and extracorporeal shock wave lithotripsy for treatment of ureteral calculi. Eur. Urol., 14, 178-180. Jenkins, A. D. and Gillenwater, J. Y. (1988). Extracorporeal shock wave lithotripsy in the prone position: treatment of stones in the distal ureter or anomalous kidney. J. Urol., 139, 911-915. Lingeman, J. E., Shimell, W. L., Newman, D. M. et d (1987). Management of upper ureteral calculi with extracorporeal shock wave lithotripsy. J. Urol., 138,720-723. Lupu, A. N., Fuchs, G. J. and Chaussy, C. (1988). Treatment of ureteral calculi by extracorporeal shock wave lithotripsy. UCLA experience. Urology, 32,217-222. Miller, K., Fuchs, G., Rassweiler, J. er d (1985). Treatment of ureteral stone disease: the role of ESWL and endourology. World J. Urol., 3,445. Tiselius, H. G., Pettersson, B., Hellgren, E. et d (1988). Classification of patients subjected to extracorporeal shock wave lithotripsy. Scand. J. Urol. Nephrol., 22,65-70. Zerbib, M., Flam, T., Belas, M. et d (1990). Clinical experience with new pulsed dye laser for ureteral stone lithotripsy. J. Urol., 143,483485.
The Authors E. Benizri, MD, Resident. M. Augusti, Assistant. G. Azoulai, MD, Assistant. L. Charbit, MD, Assistant. J. Cukier, MD, Professor. Requests for reprints to: J. Cukier, Department of Urology, HBpital Necker, 149 rue de Sbvres, 75015 Paris, France.
Extracorporeal Lithotripsy of Ureteric Calculi Using the Dornier H M-3 Lithotriptor E. BENIZRI, M. AUGUSTI, G. AZOULAI, L. CHARBIT and J. CUKIER Department of Urology, HSpital Necker, Paris, France
Summary-Over a 5-year period (November 1984-November 1989), we treated 356 patients with ureteric calculi; 170 were treated by extracorporealshock wave lithotripsy (ESWL) on a Dornier HM-3 lithotriptor. The calculi (n= 176) were uniformly distributed along the length of the ureter: 44 were just below the pelviureteric junction, 59 were lumbo-iliac, 42 were in the upper bony pelvis and 32 in the lower bony pelvis. The mean diameter of the upper ureteric calculi was 10 mm and for the others it was 8 mm. Thirty-four patients with acute obstructive pyelonephritis required preESWL drainage of the urine. X-ray localisation required intraveneous urography during lithotripsy in 52 cases (30%).On plain X-ray the following day 170 stones (96%) were judged to have disintegrated. The 6 patients whose stones were not fragmented received further treatment (ureterotomy (4) and ureteroscopy (2)). Five patients required additional treatment because of pain or fever (catheterisation (3) and ureterotomy (2)) and 2 patients had a second lithotripsy owing to insufficient fragmentation. Four patients were lost to follow-up. In 153 patients (90%) the fragments were eliminated completely, 146 in the first month and the remainder before the sixth month. No serious sequelae were observed. In addition to the 5 patients who required supplementary treatment. 11 patients with pain or fever needed medical treatment. We recommend first intention in situ ESWL for all ureteric calculi.
The aim of this study was to demonstrate the possibility of treating virtually all ureteric calculi by ESWL. Such calculi were initially excluded from ESWL by Chaussy et al. (1980, 1982). Miller et al. (1985) published the first report of success with upper ureteric calculi.
Patients and Methods In France, the first ureteric calculi were treated at the Centre Inter Etablissements de Lithotriptie of the Assistance Publique de Paris in 1984. From November 1984 to November 1989, using the Dornier HM-3 lithotriptor with X-ray localisation, 176 ureteric calculi were treated by ESWL. The study group included 170 patients (134 men and 36 women) whose mean age was 40 years (range 784). Two patients underwent 2 consecutive ESWL sessions, so that the total number of treatments was Accepted for publication 12 July 1991
172 for 170 patients. Six patients had 2 ureteric calculi, making a total of 176 calculi in 170 patients. The distribution of the stones according to size and location is shown in the Table. Before treatment all patients underwent intravenous urography (IVU), urine analysis, blood count and coagulation tests. Plain X-rays of the abdomen, AP and lateral, were done immediately before lithotripsy. In 34 patients, acute obstructive pyelonephritis required prior drainage of the urine Table Distribution of Calculi According to Position Size (mm)
Upper ureter
Lumboiliac
15 Distribution
0 33 6 5 44 (25%)
9 9 44 21 5 4 1 2 59 (33%) 42 (24%)
600
Upper pelvic
Lower pelvic 8 11
5 1 31 (18%)
ESWL USING THE DORNIER
60 1
HM-3 LITHOTRIPTOR
(32 times by a ureteric catheter alongside the (2) for inadequate fragmentation. Four patients could no longer be contacted. calculus and twice by percutaneous nephrostomy). Thus 166 patients with 172 ureteric calculi were Regardless of the position of the calculus, its initial localisation was attempted in the conven- assessed. A total of 153 patients (92%) eliminated their tional half-sitting position. If the localisation time approached 605 without having found the stone, fragments completely (146 (88%) in the first month the patient's position was changed and an IVU was and 7 (4%) before the sixth month). The 6 immediate failures have been discussed. obtained. Some iliac calculi were localised in the prone position and pelvic calculi that were uniden- Of the remaining 166 calculi, 159 were eliminated tifiable in the outstretched position were localised without supplementary treatment (92.5%). Seven in the seated position. The lack of visibility of the required supplementary treatment. In all, 164/172 calculus was sometimes overcome by performing calculi were eliminated without surgery or ureteran IVU during localisation (52 times; 30% of the oscopy (95.3%). cases). Before 1989 it was necessary to use general Discussion anaesthesia 43 times, epidural anaesthesia 78 times and sedation 17 times to supplement premedication. Of 356 ureteric calculi treated between 1984 and Of 74 treatments carried out since 1989, no general 1989, 176 were treated by ESWL, 149 by open anaesthesia was required, but 16 patients had ureterotomy and 31 by ureteroscopic extraction. epidural anaesthesia, 26 sedation as well as preme- The percentage treated by ESWL rose steadily dication, and 32 had premedication alone. The (Fig.). Thus in 1989, 70/74 ureteric calculi (94.5%) number of shock waves per calculus ranged from were destroyed by ESWL and the remaining 4 removed by ureterotomy. 2000 to 4000. For sub-pelvic, upper lumbar and lower pelvic Lithotripsy was terminated on the basis of an impression of a change in the contour of the texture calculi, regardless of the method of localisation, of the X-ray image of the calculus rather than the success rates of over 85% have been reported. When certainty of disintegration proved by the dispersion lithotriptors with ultrasound localisation were used, success rates ranged from 79 to 86.5% (unpublished of sand. The urine was usually haematuric after litho- material). For lithotriptors with X-ray localisation tripsy: in addition, 11 patients complained of the success rate was 90% (Coptcoat et al., 1987; lumbar pain and 5 had a fever ( < 38.5"C). Anti- Lingeman et al., 1987; Fetner et al., 1988; Graff et spasmodic and anti-inflammatory treatment was al., 1988; Ikemoto et al., 1988; Lupu er al., 1988; prescribed 11 times. Antibiotics were given only to Chatelain et al., 1990). Calculi in these sites are pyuric and bacteriuric patients. A plain X-ray of extremely amenable to lithotripsy, especially if the abdomen was taken on the following day to localised by X-ray. assess fragmentation. If fragmentation appeared For lumbo-iliac and upper pelvic calculi, ultrasatisfactory, follow-up was confined to plain X-ray, sound localisation produced poor results ( < 50% cytobacteriological urine analysis and renal echography 8 and 45 days later. No.
Results Patients who eliminated their stones completely were considered cured. The absence of fragmentation indicated failure and fragmentation with incomplete elimination indicated residual calculi. On the plain X-ray taken 24 h after treatment, 170/ 176 calculi were fragmented (96%). Of the 6 patients (3.5%) whose stones were not fragmented, 4 were treated by ureterotomy and 2 by ureteroscopy. Seven patients (4%) received supplementary treatment because of pain or fever, although the calculus was fragmented : ureterotomy (2 patients), catheterisation (3) and repeat ESWL
70
/
\
1/ 1 ESWL 2 Ureterotomy 3 Ureteroscopy
40
30
1985186
1986187
1987188
1988189
Fig. Treatment of ureteric calculi at HBpital Necker.
602 success rate for the former and 65% for the latter) (unpublished material). Our localisation problems were overcome by intravenous urography (52 times) during lithotripsy, combined if necessary with a change in the patient’s position. For lumbar calculi, Fetner et al. (1988) reported 138 patients (83%) cured 6 weeks after in situ ESWL without catheterisation. Our results are similar, with an 85% success rate in 1 month. For iliac calculi, 2 problems had to be overcome : interruption of the shock wave by the iliac bones and the sacrum when the waves penetrate from behind, and the ability to localise a stone positioned far in front of the focus F2 of the ellipsoid of revolution. Jenkins and Gillenwater (1988) and Tiselius et al. (1988) were the first to suggest lithotripsy in the prone position, except for sexually active women because of the risk of irradiating the ovary. Iliac localisationled to a success rate of 90% at 6 months. Jenkins and Gillenwater (1988) and Tiselius et al. (1988) reported success rates of 93 and 87.5% respectively. These good results can be ascribed to X-ray localisation. This zone is invisible to those using ultrasound localisation. For upper pelvic calculi, opinions vary. Some authors feel that pelvic stones are amenable to ureteroscopic extraction (Coptcoat et al., 1987; Ikemoto et al., 1988; Zerbib et al., 1990), but we believe it is simpler to use ESWL first. In the present series, 42 upper pelvic calculi were treated in situ without endoscopic manipulation, with a 93% success rate after 1 month. Chatelain et al. (1990) reported a success rate of 98%. Two calculi that were superimposed on the transverse process of L5 could not be localised despite using all of the methods described above and they were treated by ureterotomy. Four calculi (2 pelvic, 1 lumbar and 1 sub-pelvic) underwent ESWL without fragmentation. The absence of postESWL haematuria in these patients leads us to believe that the shock waves were not focused on the urinary tract. Two patients underwent ureterotomy and 2 ureteroscopy. A success rate of 96.5% at 6 months justifies our claim that in situ ESWL with an X-ray localisation lithotriptor is an excellent method for treating
BRITISH JOURNAL OF UROLOGY
radio-opaque ureteric calculi, irrespective of their position.
References Chatelain, C., Connort, P., Ledenko, N. et d (1990). Lithotriptie extra-corporelle par ondes de choc klectromagnktiques. Premiers rksultats dans le traitement de la lithiase urtrtkrale in situ. SCrie de 50 cas conskcutifs. Ann. Urol. (Paris), 3, 232235. Chaussy, C., Breudel, W. and Schmidt, E. (1980). Extracorporeally induced destruction of kidney stones by shock waves. Lancet, 2, 1265. Chaussy, C., Schmidt, E., Jocham, D. et al. (1982). First clinical experience with extracorporeally induced destruction of kidney stones by shock waves. J. Urol., 127,417420. Coptcoat, M. J., Webb, D. R., Kellett, M. J. et d (1987). The treatment of 100 consecutive patients with ureteral calculi in a British Stone Centre. J. Urol., 137, 1122-1 123. Fetner, C. D., Preminge, G. M., Seger, J. e t d (1988). Treatment of ureteral calculi by extracorporeal shock wave lithotripsy at a multi-use centre. J. Urol., 139,1192-1 194. Graff, J., Pastor, J., Funke, P. J. et d (1988). Extracorporeal shock wave lithotripsy for ureteral stones: a retrospective analysis of 417 cases. J. Urol., 139, 513-516. Ikemoto, S., Sugimoto, T., Yamamoto, K. et d (1988). Comparison of transurethral ureteroscopy and extracorporeal shock wave lithotripsy for treatment of ureteral calculi. Eur. Urol., 14, 178-180. Jenkins, A. D. and Gillenwater, J. Y. (1988). Extracorporeal shock wave lithotripsy in the prone position: treatment of stones in the distal ureter or anomalous kidney. J. Urol., 139, 911-915. Lingeman, J. E., Shimell, W. L., Newman, D. M. et d (1987). Management of upper ureteral calculi with extracorporeal shock wave lithotripsy. J. Urol., 138,720-723. Lupu, A. N., Fuchs, G. J. and Chaussy, C. (1988). Treatment of ureteral calculi by extracorporeal shock wave lithotripsy. UCLA experience. Urology, 32,217-222. Miller, K., Fuchs, G., Rassweiler, J. er d (1985). Treatment of ureteral stone disease: the role of ESWL and endourology. World J. Urol., 3,445. Tiselius, H. G., Pettersson, B., Hellgren, E. et d (1988). Classification of patients subjected to extracorporeal shock wave lithotripsy. Scand. J. Urol. Nephrol., 22,65-70. Zerbib, M., Flam, T., Belas, M. et d (1990). Clinical experience with new pulsed dye laser for ureteral stone lithotripsy. J. Urol., 143,483485.
The Authors E. Benizri, MD, Resident. M. Augusti, Assistant. G. Azoulai, MD, Assistant. L. Charbit, MD, Assistant. J. Cukier, MD, Professor. Requests for reprints to: J. Cukier, Department of Urology, HBpital Necker, 149 rue de Sbvres, 75015 Paris, France.
